6/2/17

These 101 Words May Have Pushed Opioids Into Dangerous Popularity

As Americans around the country battle opioid addiction, and health officials and lawmakers try to find a way to stem the rising tide of painkiller overdose deaths, everyone is looking for answers as to how we got here. Now, a new report says five simple sentences made up of just 101 words on addiction to narcotic painkillers in a 1980 medical journal may have a lot to do with it.

In a one-paragraph letter to the editor in a 1980 issue of the New England Journal of Medicine, Jane Porter and Dr. Hershel Jick of the Boston Collaborative Drug Surveillance Program describe an analysis of 11,822 hospital patients who had taken a narcotic painkiller at least once.

Most of those patients tolerated it without incident, they wrote, and “there were only four cases of reasonably well documented addiction in patients who had no history of addiction,” adding that the addiction was considered major in only one instance.

The authors concluded that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

But with more than 183,000 deaths from prescription opioids between 1999 through 2015, that letter turned out to be terribly wrong. And according to the authors of a new report in the NEJM, the current epidemic can be blamed partly on this letter.

“The crisis arose in part because physicians were told that the risk of addiction was low when opioids were prescribed for chronic pain, write researchers led by Pamela T.M. Leung of the University of Toronto.

They performed a bibliometric analysis of the letter from the time it was published through March 30, 2017, and found it had been cited 608 times, including “a sizable increase after the introduction of OxyContin” in 1995.

That’s a lot: Leung and her colleagues found 11 other letters to the editor published within four weeks of this one, and the median number of citations for those other letters was just 11.

But it’s not just that the letter was mentioned so often, it’s the way that many authors of these articles interpreted it, researchers say. To that end, the authors of 491 articles “did not note that the patients who were described in the letter were hospitalized at the time they received the prescription,” Leung notes. Outpatients who were already at home could have been addicted away from the watchful eyes of doctors.

Other authors “grossly misrepresented the conclusions of the letter,” researchers say, like a 1999 report in Nursing Economics in which a nurse practitioner at the University of Massachusetts Memorial Center wrote: “This pain population with no abuse history is literally at no risk for addiction.”

This letter was “heavily and uncritically cited as evidence that addiction was rare with long-term opioid therapy,” Leung writes, and as such, it has contributed to our current opioid crisis “by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.”

Leung and her colleagues note that in 2007, the manufacturer of OxyContin and three senior executives pleaded guilty to federal criminal charges that they misled regulators, doctors, and patients about the risk of addiction associated with the drug.

And more recently, authorities in Ohio filed a lawsuit accusing Purdue Pharma; Endo (Percocet); Teva (Fentora); Johnson & Johnson’s Janssen (Duragesic); and Allergan (Norco) of operating marketing campaigns that “falsely deny or trivialize the risks of opioids while overstating the benefits of using them for chronic pain.”

Leung and her fellow researchers say their findings highlight the potential consequences of inaccurately citing medical articles, and “underscore the need for diligence when citing previously published studies.”